Cases That Test Your Skills

Steroid abuse: a ‘hidden’ health hazard

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References

What medical sequelae await Mr. A if he continues to abuse steroids? How would you convince him to stay in treatment?

Dr. Carter’s and Pope’s observations

Mr. A’s path to mania has been well demonstrated in the literature. Hypomania or even frank manic syndromes, sometimes associated with violent behavior, are rare at weekly doses of 300 mg of testosterone equivalent. At weekly doses of >1,000 mg, psychiatric syndromes such as hypomania or mania may occur in almost one-half of cases.5

If he continues to abuse anabolic steroids, however, Mr. A could experience adverse physical reactions ranging from embarrassing acne and male-pattern baldness (Table 1) to rare and life-threatening hepatic effects such as cholestatic jaundice and peliosis hepatitis (blood-filled cysts in the liver).

Table 1

ANABOLIC STEROID ABUSE: COMMON PHYSICAL FINDINGS

  • Hypertrophic muscularity, disproportionately in upper torso
  • Acne on face, shoulders, and back
  • Male-pattern baldness
  • Testicular atrophy and gynecomastia in men
  • Clitoral enlargement, decreased breast size, hirsutism, and deepening of voice in women
Source: Adapted from Brower KJ. Anabolic steroid abuse and dependence. Curr Psychiatry Rep 2002;4:377-83.

The risk of atherosclerotic disease or prostate cancer later in life may also be greatly increased.

More common laboratory changes include:

  • increased red blood cell count, hemoglobin and hematocrit
  • elevated liver function readings (although these must not be confused with enzymes that originate from muscle tissue)
  • and unfavorable changes in triglycerides, total cholesterol, and HDL:LDL cholesterol ratios (Table 2).

Other potential laboratory changes with steroid abuse include decreased luteinizing hormone and follicle-stimulating hormone due to feedback inhibition. Feedback inhibition will also reduce testosterone and estradiol levels with use of anabolic steroids other than testosterone esters. These levels, however, would both be elevated with use of testosterone esters alone.

In men, testicular atrophy and decreased sperm count are generally reversible manifestations of steroid abuse, whereas gynecomastia may be irreversible and require surgical intervention in advanced cases.3,6 Women who use anabolic steroids (such as for body-building) are vulnerable to disrupted menstrual cycles, decreased breast size, and masculinizing effects including enlarged clitoris, hirsutism, and deepening of the voice.6

In adolescents, anabolic steroid use may cause premature closure of the epiphyses, leading to shortened stature.3

Unfortunately, warnings about these many adverse effects rarely deter anabolic steroid users such as Mr. A or persuade them to continue in treatment of any type. Most young anabolic steroid abusers report that they have never felt significant adverse effects from steroid use and know of no one who has experienced such effects. The dramatic muscle gains they have witnessed in themselves and in other users decisively outweigh what they perceive to be remote threats of adverse consequences.

Follow-up: Return to treatment

We didn’t hear from Mr. A until about 18 months later, when he unexpectedly requested a consultation.

Upon arrival, Mr. A exhibited major depression with prominent anhedonia, hypersomnia of 12 to 14 hours per night, loss of appetite, fatigue, prominent psychomotor retardation, feelings of guilt, difficulty concentrating, and suicidal thoughts (but without a frank plan). He also reported panic attacks that were randomly occurring each day, usually in public.

Mr. A conceded that he had experienced similar depressive episodes after stopping anabolic steroid use, but that they typically ran their course after 2 to 3 weeks. He said the present episode showed no sign of abating after nearly 2 months. He had attempted to ‘treat’ this episode by resuming anabolic steroid use, but he could not get an adequate supply from his dealer.

Mr. A’s total testosterone level, measured in the morning when it should be near its diurnal peak, was 127 ng/dl (normal range is 270 to 1,070 ng/dl). Physical examination revealed that his testicles had shrunk to the size of marbles (each approximately 5 mm in diameter). He was referred to an endocrinologist for evaluation and was simultaneously started on fluoxetine, 20 mg/d.

Table 2

LABORATORY ABNORMALITIES ASSOCIATED WITH ANABOLIC STEROID ABUSE

  • Elevated red blood cell count and hematocrit
  • Unfavorable lipid profile changes
  • Changes in LH, FSH, testosterone, and estradiol levels
  • Reduced sperm cell count
Source: Adapted from Brower KJ. Anabolic steroid abuse and dependence. Curr Psychiatry Rep 2002;4:377-83.

He returned 2 weeks later, exhibiting little improvement and wanting to resume steroids ‘because it was the only thing that really helped.’ Instead, he agreed to continue on fluoxetine and remain in follow-up. At 4 weeks, he noticed a decrease in panic attacks, return of normal mood, decreased anhedonia, and loss of suicidal ideation. He continued taking fluoxetine for another 3 months but then abruptly disappeared from treatment.

Mr. A resurfaced about 1 year later, revealing to the psychiatrist that he had taken yet another cycle of anabolic steroids, largely because he feared losing his muscle mass. His panic attacks had recurred almost immediately when he began tapering down from the peak of this cycle, and he agreed to resume taking fluoxetine.

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